and their inclusion herein does not imply endorsement by McKesson of modifications.
NOTES:
This document provides a high-level summary of customizations and modifications made to McKesson InterQual® Criteria (from now on referred to as Customized Criteria).
Customized Criteria are available on request.
Benefit plans vary in coverage, and some plans may not provide coverage for certain services discussed in the Customized Criteria. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and applicable state and/or federal law. The Customized Criteria do not constitute plan authorization or a guarantee of payment, nor are they an explanation of benefits.
We reserve the right to review and modify the InterQual® Criteria or Customized Criteria at any time.
No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
The 2013 Edition of the InterQual® Criteria and corresponding Customized Criteria will take effect May 1, 2013.
The March 21, 2013, Amerigroup Medical Policy Committee review date reflects review and approval of (a) the licensed 2013 InterQual® Criteria and (b) customizations to the 2013 Edition.
The May 13, 2013 Amerigroup Medical Operations Committee (formerly Medical Policy Committee) review date reflects review and approval of (a) the licensed 2013 InterQual® Criteria and (b) customizations to the 2013 Edition.
The September 4, 2013 Amerigroup Medical Operations Committee review date reflects review and approval of the following changes to existing customizations to the 2013.2 Edition:
o Customizations Care Planning (CP) Procedures
Video Electroencephalographic (EEG) Monitoring
Video Electroencephalographic (EEG) Monitoring (Pediatric)
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Orthoses, Cranial Remodeling
Orthoses, Spinal
Orthoses, Spinal - Senior
Prosthetics, Above Knee and Below Knee
Prosthetics, Above Knee and Below Knee - Senior
Prosthetics, Lower Extremity
Prosthetics, Lower Extremity - Senior
Prosthetics, Microprocessor-controlled, Knee
Secretion Clearance Devices
Secretion Clearance Devices - Senior
Standing Frames CUSTOMIZATIONS LEVEL OF CARE: OUTPATIENT REHABILITATION & CHIROPRACTIC
Traumatic Brain Injury (TBI): Rehabilitation (Adult) CUSTOMIZATION HISTORY Return to Index
CUSTOMIZATIONS – BACKGROUND INFORMATION
Types of Customizations: 1. Customizations to InterQual® criteria are based on integration with our medical policy.
2. Customization to InterQual® criteria may include replacing the criteria with a note to use a
medical policy or clinical utilization management guideline.
3. Customizations to InterQual® criteria may include adding an Organizational Policy Note to see a related medical policy.
Review and Approval of Customizations: The Amerigroup Medical Operations Committee (MOC) (formerly Medical Policy Committee [MPC]) reviews and approves all customizations to InterQual® criteria. In addition, when a new edition of InterQual® criteria is released, the new edition is reviewed and approved by the MPC.
Disclaimer: The list of customized guidelines includes a disclaimer indicating:
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
CUSTOMIZATIONS CARE PLANNING (CP) PROCEDURES (ADULT AND PEDIATRIC)
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Angioplasty and Stent, Carotid
March 21, 2013 AGP MPC review: o Removed criteria and replaced with the following: Angioplasty and Stent, Carotid (May 1, 2013) For carotid angioplasty and stent, see SURG.00001 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement.
Antireflux Procedures, Endoscopic
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Antireflux Procedures, Endoscopic May 1, 2013) NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease. NOTE: For in vivo analysis of gastrointestinal lesions, see MED.00077 In-Vivo Analysis of
Gastrointestinal Lesions. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia" Organizational Policy (Antireflux Procedures, Endoscopic August 08, 2013) NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia.
NOTE: For in vivo analysis of gastrointestinal lesions, see MED.00077 In-Vivo Analysis of Gastrointestinal Lesions.
Antireflux Surgery or Hiatal Hernia Repair
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Antireflux Surgery or Hiatal Hernia Repair May 1, 2013) NOTE: For lower esophageal sphincter augmentation devices for the treatment of
gastroesophageal reflux disease (GERD), see SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD).
Aortic Valve Replacement (AVR)
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Aortic Valve Replacement [AVR] May 1, 2013)
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
NOTE: When the procedure uses the transcatheter approach (as opposed to open), see SURG.00121 Transcatheter Heart Valves.
Arthroscopy, Surgical, Ankle
May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Arthroscopy, Surgical, Ankle May 13, 2013) NOTE: For treatment of osteochondral defects, see SURG.00093 Treatment of Osteochondral
Defects.
Arthrotomy, Hip March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Arthrotomy, Hip May 1, 2013) NOTE: For hip resurfacing, see SURG.00051 Hip Resurfacing. NOTE: For surgical treatment of femoroacetabular impingement syndrome (FAIS), see
SURG.00109 Surgical Treatment of Femoroacetabular Impingement Syndrome. NOTE: For sacroiliac joint fusion, see SURG.00127 Sacroiliac Joint Fusion.
Arthrotomy, Knee March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Arthrotomy, Knee May 1, 2013) NOTE: For bicompartmental knee arthroplasty, see SURG.00105 Bicompartmental Knee
Arthroplasty.
Artificial Disc Replacement, Cervical
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Artificial Disc Replacement, Cervical (May 1, 2013) For cervical artificial disc replacement, see SURG.00055 Cervical Artificial Intervertebral Discs.
Artificial Disc Replacement, Lumbar
May 13, 2013 AGP MOC review: Removed criteria and replaced with the following: Artificial Disc Replacement, Lumbar (May 13, 2013) For lumbar artificial disc replacement, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID).
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Atrial Septal Defect (ASD) Repair
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Atrial Septal Defect (ASD) Repair May 1, 2013) NOTE: For transcatheter closure of patent foramen ovale and left atrial appendage for
stroke prevention, see SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention.
Bariatric Surgery March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Bariatric Surgery (May 1, 2013) For bariatric surgery, see SURG.00024 Surgery for Clinically Severe Obesity.
Bone Augmentation, Mandible
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Bone Augmentation, Mandible (May 1, 2013) For bone augmentation, mandible, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: For facial plastic surgery, see ANC.00008 Cosmetic and Reconstructive Services
of the Head and Neck.
Bone Augmentation, Maxilla
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Bone Augmentation, Maxilla (May 1, 2013) For bone augmentation, maxilla, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: For facial plastic surgery, see ANC.00008 Cosmetic and Reconstructive Services
of the Head and Neck.
Bone Graft and Implantable Stimulator, Fracture Nonunion
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Bone Graft and Implantable Stimulator, Fracture Nonunion (May 1, 2013) For bone graft and implantable stimulator, fracture nonunion, see DME.00004 Electrical Bone Growth Stimulation.
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Brachytherapy, Prostate
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Brachytherapy, Prostate (May 1, 2013) For prostate brachytherapy, see RAD.00014 Brachytherapy for Oncologic Indications.
Breast Implant Removal
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Breast Implant Removal (May 1, 2013) For breast implant removal, see SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures.
Breast Reconstruction
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Breast Reconstruction (May 1, 2013) For breast reconstruction, see SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures.
Capsule Endoscopy March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Capsule Endoscopy (May 1, 2013) For capsule endoscopy, see RAD.00030 Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule.
Cataract Removal March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy ( Cataract Removal May 1, 2013) NOTE: When the procedure is clear lens extraction with or without implantation of an
accommodating or nonaccommodating lens, see SURG.00009 Refractive Surgery.
Cochlear Implantation
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Cochlear Implantation (May 1, 2013)
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
For cochlear implantation, see SURG.00014 Cochlear Implants and Auditory Brainstem Implants.
Cochlear Implantation (Pediatric)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Cochlear Implantation (Pediatric) (May 1, 2013) For cochlear implantation (pediatric), see SURG.00014 Cochlear Implants and Auditory Brainstem Implants.
Discectomy, Lumbar
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Discectomy, Lumbar May 1, 2013) NOTE: When the procedure uses the percutaneous or endoscopic approach (as
opposed to open with direct visualization), see SURG.00071 Percutaneous and Endoscopic Spinal Surgery.
Electrocardiogra-phy, Ambulatory
May 13, 2013 MOC review: Removed criteria and replaced with the following: Electrocardiography, Ambulatory (May 13, 2013) For ambulatory event monitors, see CG-MED-40 Ambulatory Event Monitors to Detect Cardiac Arrhythmias. For Holter monitors, see CG-MED-44 Holter Monitors. NOTE: For real-time remote heart monitors, see MED.00051 Real-Time Remote Heart
Monitors. March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Electrocardiography, Ambulatory May 1, 2013) NOTE: For real-time remote heart monitors, see MED.00051 Real-Time Remote Heart
Monitors.
Electrophysiology (EP) Testing
March 21, 2013 AGP MPC review: Added Organizational Policy:
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Organizational Policy (Electrophysiology [EP] Testing May 1, 2013) NOTE: When the procedure is transcatheter ablation of arrhythmogenic foci in the
pulmonary veins, see MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation).
Endoscopy, Upper Gastrointestinal (EGD)
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] May 1, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG.00106
Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease. NOTE: For in vivo analysis of gastrointestinal lesions, see MED.00077 In-Vivo Analysis of
Gastrointestinal Lesions. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia" Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] August 08, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG.00106
Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia.
NOTE: For in vivo analysis of gastrointestinal lesions, see MED.00077 In-Vivo Analysis of Gastrointestinal Lesions.
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] [Pediatric] May 1, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG.00106
Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease. September 4, 2013 AGP MOC review: Revision: Medical Policy retitled. Added "and Dysphagia"
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Organizational Policy (Endoscopy, Upper Gastrointestinal [EGD] [Pediatric] August 08, 2013) NOTE: For ablative techniques as a treatment for Barrett's esophagus, see SURG.00106
Ablative Techniques as a Treatment for Barrett's Esophagus. NOTE: For transendoscopic therapy for gastroesophageal reflux disease, see
SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia.
Endovascular Repair, Aortic Aneurysm
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Endovascular Repair, Aortic Aneurysm (May 1, 2013) For endovascular repair of abdominal aortic aneurysm, see SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection.
Endovenous Ablation, Varicose Veins
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Endovenous Ablation, Varicose Veins (May 1, 2013) For endovenous ablation, varicose veins, see SURG.00037 Treatment of Varicose Veins (Lower Extremities).
Epidural Catheter Placement
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Epidural Catheter Placement May 1, 2013) NOTE: For implantable infusion pumps, see SURG.00068 Implantable Infusion Pumps.
Ethmoidectomy March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Ethmoidectomy May 1, 2013) NOTE: When the procedure is for the treatment of chronic headaches, see SURG.00096
Surgical and Ablative Treatments for Chronic Headaches.
Facet Joint Injection
May 13, 2013 AGP MOC review: Removed criteria and replaced with the following:
Facet Joint Injection (May 13, 2013) For facet joint injection, see CG-SURG-32 Pain Management: Cervical, Thoracic & Lumbar
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Facet Injection.
Facial Nerve Repair March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Facial Nerve Repair May 1, 2013) NOTE: For facial plastic surgery, see ANC.00008 Cosmetic and Reconstructive Services
of the Head and Neck.
Fusion, Cervical Spine
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Fusion, Cervical Spine May 1, 2013) NOTE: For facet joint allograft implant(s), see SURG.00114 Facet Joint Allograft Implants
for Facet Disease.
Fusion, Lumbar Spine
May 13, 2013 AGP MOC review: Removed criteria and replaced with the following: Fusion, Lumbar Spine (May 13, 2013) For lumbar spine fusion, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial Intervertebral Disc (LAID).
Fusion, Thoracic Spine
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Fusion, Thoracic Spine May 1, 2013) NOTE: For facet joint allograft implant(s), see SURG.00114 Facet Joint Allograft Implants
for Facet Disease.
Gastric Stimulation March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Gastric Stimulation (May 1, 2013) For gastric stimulation, see SURG.00046 Gastric Electrical Stimulation.
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
For implantable cardioverter defibrillator (ICD) insertion, see the following: SURG.00033 Implantable Cardioverter-Defibrillator (ICD) SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable
Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure
Interspinous Process Decompression
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Interspinous Process Decompression (May 1, 2013) For interspinous process decompression, see SURG.00092 Implanted Devices for Spinal Stenosis.
Keratoplasty March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Keratoplasty May 1, 2013) NOTE: For endothelial keratoplasty, see SURG.00108 Endothelial Keratoplasty. NOTE: For keratomileusis, see SURG.00009 Refractive Surgery.
Laminectomy, Lumbar, +/- Fusion
May 13, 2013 AGP MOC review: Added Organizational Policy: Organizational Policy (Laminectomy, Lumbar, +/- Fusion May 13, 2013) NOTE: For lumbar fusion, see CG-SURG-33 Lumbar Fusion and Lumbar Artificial
Intervertebral Disc (LAID).
Left Ventricular Assist Device (LVAD) Insertion
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Left Ventricular Assist Device (LVAD) Insertion (May 1, 2013) For left ventricular assist device (LVAD) insertion, see TRANS.00014 Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts).
Liposuction March 21, 2013 AGP MPC review: Added Organizational Policy
Organizational Policy (Liposuction May 1, 2013) NOTE: Several medical policies address liposuction; review medical policies first to
determine if they address the service requested before using InterQual.
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Lung Volume Reduction Surgery (LVRS)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Lung Volume Reduction Surgery (LVRS) (May 1, 2013) For lung volume reduction surgery (LVRS), see SURG.00022 Lung Volume Reduction Surgery.
Manipulation Under Anesthesia, Shoulder
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Manipulation Under Anesthesia, Shoulder (May 1, 2013) For manipulation under anesthesia, shoulder, see MED.00079 Manipulation Under Anesthesia of the Spine and Joints other than the Knee.
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Maxillary Buttress Osteotomies, +/- Mid Palatal Osteotomy (May 1, 2013) For maxillary buttress osteotomies, +/- mid palatal osteotomy, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea.
Maxillectomy March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Maxillectomy (May 1, 2013) For maxillectomy, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery.
Neuroablation, Percutaneous
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Neuroablation, Percutaneous May 1, 2013) NOTE: Several medical policies address percutaneous neuroablation; review medical
policies first to determine if they address the service requested before using InterQual.
Osteotomy, Anterior Segment, Mandible
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Osteotomy, Anterior Segment, Mandible (May 1, 2013) For osteotomy, anterior segment, mandible, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea.
Osteotomy, Anterior Segment, Maxilla
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Osteotomy, Anterior Segment, Maxilla (May 1, 2013) For osteotomy, anterior segment, maxilla, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea.
Osteotomy, LeFort I
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Osteotomy, LeFort I (May 1, 2013) For osteotomy, LeFort I, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery.
Osteotomy, Mandible Ramus
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Osteotomy, Mandible Ramus (May 1, 2013) For osteotomy, mandible ramus, see SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea.
Osteotomy, Posterior Segment, Maxilla
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Osteotomy, Posterior Segment, Maxilla (May 1, 2013) For osteotomy, posterior segment, maxilla, see SURG.00049 Mandibular/Maxillary
Subject: Customizations to McKesson InterQual® Criteria
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Pacemaker Insertion, Biventricular +/- ICD Insertion (May 1, 2013) For Pacemaker Insertion, Biventricular +/- ICD insertion, see the following: SURG.00064 Cardiac Resynchronization Therapy (CRT) with or without an Implantable
Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure SURG.00033 Implantable Cardioverter-Defibrillator (ICD)
Panniculectomy, Abdominal
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Panniculectomy, Abdominal (May 1, 2013) For abdominal panniculectomy, see SURG.00048 Panniculectomy and Abdominoplasty.
Pectus Excavatum Repair (Pediatric)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Pectus Excavatum Repair (Pediatric) (May 1, 2013) For pectus excavatum repair, see ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin.
Percutaneous Coronary Interventions (PCI)
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Percutaneous Coronary Interventions (PCI) May 1, 2013) NOTE: For coronary intravascular brachytherapy, see RAD.00016 Intravascular
Brachytherapy (Coronary and Non-Coronary).
Photocoagulation, Focal Laser
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Photocoagulation, Focal Laser May 1, 2013) NOTE: For photocoagulation of macular drusen, see SURG.00070 Photocoagulation of
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Macular Drusen.
Photocoagulation, Grid Laser
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Photocoagulation, Grid Laser May 1, 2013) NOTE: For photocoagulation of macular drusen, see SURG.00070 Photocoagulation of
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Plantar Fasciitis, Extracorporeal Shock Wave Therapy (ESWT) (May 1, 2013) For extracorporeal shock wave therapy (ESWT) for plantar fasciitis, see SURG.00045 Extracorporeal Shock Wave Therapy for Orthopedic Conditions.
Polypectomy, Nasal
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Polypectomy, Nasal May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring.
Polysomnogram (PSG)
May 13, 2013 MOC review: Added Organizational Policy:
Organizational Policy (Polysomnogram [PSG] May 13, 2013) NOTE: For actigraphy testing, see MED.00002 Selected Sleep Testing Services.
Polysomnogram (PSG) (Pediatric)
May 13, 2013 MOC review: Added Organizational Policy:
Organizational Policy (Polysomnogram [PSG] [Pediatric] May 13, 2013) NOTE: For actigraphy testing, see MED.00002 Selected Sleep Testing Services.
Prostatectomy, Transurethral Ablation
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
For transurethral ablation of the prostate, see SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions.
Prostatectomy, Transurethral Resection
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Prostatectomy, Transurethral Resection May 1, 2013) NOTE: For laser-based procedures, transurethral incision of the prostate, and
transurethral vapor resection of the prostate, see SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions.
Proton Beam Radiotherapy (PBRT)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Proton Beam Radiotherapy (PBRT) (May 1, 2013) For proton beam radiotherapy (PBRT), see RAD.00015 Proton Beam Radiation Therapy.
Ptosis Repair December 12, 2013 AGP MPC review: Removed customization based on McKesson removing coding related to SURG.00096
Surgical and Ablative Treatments for Chronic Headaches. March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Ptosis Repair May 1, 2013) NOTE: When the procedure is for the treatment of chronic headaches, see SURG.00096
Surgical and Ablative Treatments for Chronic Headaches.
Radiofrequency Ablation (RFA) or Chemoemboliza- tion, Liver
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Radiofrequency Ablation (RFA) or Chemoembolization, Liver (May 1, 2013) For radiofrequency ablation (RFA) or chemoembolization, liver, see the following: RAD.00011 Transcatheter Arterial Chemoembolization (TACE) and Transcatheter
Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors SURG.00065 Locally Ablative Techniques for Treating Primary and Metastatic Liver
Malignancies
NOTE: For related procedures, see the following: RAD.00033 Selective Internal Radiation Therapy (SIRT) of Primary or Metastatic Liver
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Tumors (i.e., SIR-Sphere and TheraSpheres) SURG.00126 Irreversible Electroporation (IRE)
Radiofrequency Ablation (RFA), Cardiac
March 21, 2013 AGP MPC review: Added Organizational Policy:
Organizational Policy (Radiofrequency Ablation [RFA], Cardiac May 1, 2013) NOTE: When the procedure is transcatheter ablation of arrhythmogenic foci in the
pulmonary veins, see MED.00064 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation).
Radiofrequency Ablation (RFA), Renal
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Radiofrequency Ablation (RFA), Renal (May 1, 2013) For radiofrequency ablation (RFA), renal, see SURG.00050 Radiofrequency Ablation to Treat Tumors Outside the Liver.
Reconstruction, Temporomandibu-lar Joint (TMJ)
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Reconstruction, Temporomandibular Joint [TMJ] May 1, 2013) NOTE: For facial plastic surgery, see ANC.00008 Cosmetic and Reconstructive Services
of the Head and Neck.
Reduction Mammoplasty, Female
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Reduction Mammoplasty, Female (May 1, 2013) For reduction mammoplasty, female, see SURG.00086 Reduction Mammaplasty.
NOTE: For related procedures, see the following: SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other
Breast Procedures
Reduction Mammoplasty, Male
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Reduction Mammoplasty, Male (May 1, 2013) For reduction mammoplasty, male, see SURG.00085 Mastectomy for Gynecomastia.
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
NOTE: For related procedures, see the following: SURG.00086 Reduction Mammaplasty SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other
Breast Procedures
Rhinoplasty March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Rhinoplasty (May 1, 2013) For rhinoplasty, see ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck.
Sclerotherapy, Varicose Veins
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Sclerotherapy, Varicose Veins (May 1, 2013) For sclerotherapy, varicose veins, see SURG.00037 Treatment of Varicose Veins (Lower Extremities).
Scoliosis Surgery May 13, 2013 MOC review: Added Organizational Policy:
Organizational Policy (Scoliosis Surgery May 13, 2013) NOTE: For lumbar fusion for degenerative scoliosis, see CG-SURG-33 Lumbar Fusion and
Lumbar Artificial Intervertebral Disc (LAID).
Skin Graft
May 13, 2013 MOC review: Added Organizational Policy: Organizational Policy (Skin Graft, May 13, 2013) NOTE: For allogeneic, xenographic, synthetic and composite products for wound healing and soft
tissue grafting, see SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting.
Septoplasty March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Septoplasty May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring.
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
NOTE: When the procedure is for the treatment of chronic headaches, see SURG.00096 Surgical and Ablative Treatments for Chronic Headaches.
Spinal Cord Stimulator (SCS) Insertion
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Spinal Cord Stimulator (SCS) Insertion (May 1, 2013) For spinal cord stimulator (SCS) insertion, see SURG.00060 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS).
Stereotactic Introduction, Subcortical Electrodes
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Stereotactic Introduction, Subcortical Electrodes (May 1, 2013) For stereotactic introduction, subcortical electrodes, see SURG.00026 Deep Brain Stimulation.
Stereotactic Radiosurgery, Brain or Skull Base
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Stereotactic Radiosurgery, Brain or Skull Base (May 1, 2013) For stereotactic radiosurgery, brain or skull base, see SURG.00017 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT). NOTE: For related information, see the following: RAD.00015 Proton Beam Radiation Therapy
Sympathectomy March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Sympathectomy May 1, 2013) NOTE: For treatment of hyperhidrosis, see MED.00032 Treatment of Hyperhidrosis
Sympathetic Blockade
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Sympathetic Blockade May 1, 2013) NOTE: For treatment of hyperhidrosis, see MED.00032 Treatment of Hyperhidrosis
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Thoracic or Thoracoabdominal Aortic Aneurysm Repair
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Thoracic or Thoracoabdominal Aortic Aneurysm Repair May 1, 2013) NOTE: For endovascular/ endoluminal repair of thoracic/ thoracoabdominal aortic
aneurysm, see SURG.00054 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection.
Total Joint Replacement (TJR), Ankle
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Total Joint Replacement (TJR), Ankle (May 1, 2013) For total joint replacement (TJR), ankle, see SURG.00081 Total Ankle Replacement.
Total Joint Replacement (TJR), Knee
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Total Joint Replacement [TJR], Knee May 1, 2013) NOTE: For bicompartmental knee arthroplasty, see SURG.00105 Bicompartmental Knee
Arthroplasty.
Transplantation, Allogeneic Stem Cell
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Transplantation, Allogeneic Stem Cell (May 1, 2013) For allogeneic stem cell transplantation, see the applicable medical policy.
Transplantation, Autologous Stem Cell
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Transplantation, Autologous Stem Cell (May 1, 2013) For autologous stem cell transplantation, see the applicable medical policy.
Transplantation, Cardiac
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Transplantation, Cardiac (May 1, 2013) For cardiac transplantation, see TRANS.00033 Heart Transplantation.
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Transplantation, Liver
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Transplantation, Liver (May 1, 2013) For liver transplantation, see TRANS.00008 Liver Transplantation.
Transplantation, Renal
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Transplantation, Renal May 1, 2013) NOTE: For pancreas kidney transplantation, see TRANS.00011 Pancreas Transplantation
and Pancreas Kidney Transplantation.
Turbinectomy, Inferior, Partial
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy ( Turbinectomy, Inferior, Partial May 1, 2013) NOTE: When the procedure is for the treatment of obstructive sleep apnea (OSA), see
SURG.00074 Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) and Snoring.
NOTE: When the procedure is for the treatment of chronic headaches, see SURG.00096 Surgical and Ablative Treatments for Chronic Headaches.
Uvulopalatophar-yngoplasty (UPPP)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Uvulopalatopharyngoplasty (UPPP) (May 1, 2013) For uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP), see SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea.
Vagal Nerve Stimulator
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Vagal Nerve Stimulator (May 1, 2013) For vagal nerve stimulator, see SURG.00007 Vagus Nerve Stimulation.
Vertebroplasty or Kyphoplasty
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Vertebroplasty or Kyphoplasty (May 1, 2013) For vertebroplasty or kyphoplasty, see SURG.00067 Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty).
Video Electroencephal-ographic (EEG) Monitoring
May 13, 2013 MOC review: Added Organizational Policy:
Organizational Policy (Video Electroencephalographic [EEG] May 13, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46
Ambulatory Electroencephalography. September 4, 2013 MOC review: Correct GL Title: Added "Monitoring"
Organizational Policy (Video Electroencephalographic [EEG] Monitoring August 08, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46
Ambulatory Electroencephalography.
Video Electroencephal-ographic (EEG) Monitoring (Pediatric)
May 13, 2013 MOC review: Added Organizational Policy:
Organizational Policy (Video Electroencephalographic [EEG] [Pediatric]) May 13, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46
Ambulatory Electroencephalography. September 4, 2013 MOC review: Correct GL Title: Added "Monitoring"
Organizational Policy (Video Electroencephalographic [EEG] Monitoring [Pediatric] August 08, 2013) NOTE: For ambulatory electroencephalographic (EEG) monitoring, see CG-MED-46
Ambulatory Electroencephalography.
Return to Index
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
CUSTOMIZATIONS CARE PLANNING (CP) DURABLE MEDICAL EQUIPMENT
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Bone Growth Stimulators, Noninvasive
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Bone Growth Stimulators, Noninvasive (May 1, 2013) For noninvasive bone growth stimulators, see the following: DME.00027 Ultrasound Bone Growth Stimulation DME.00004 Electrical Bone Growth Stimulation
Bone Growth Stimulators, Noninvasive - Senior
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Bone Growth Stimulators, Noninvasive - Senior (May 1, 2013) For noninvasive bone growth stimulators, see the following: DME.00027 Ultrasound Bone Growth Stimulation DME.00004 Electrical Bone Growth Stimulation
Cardioverter Defibrillator, Wearable (WCD)
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following:
Cardioverter Defibrillator, Wearable (WCD) (May 1, 2013) For wearable cardioverter defibrillator, see MED.00055 Wearable Cardioverter Defibrillators.
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Wound Therapy (NPWT) Pump - Senior
Removed criteria and replaced with the following: Negative Pressure Wound Therapy (NPWT) Pump - Senior (May 1, 2013) For negative pressure wound therapy (NPWT) pump, see DME.00009 Vacuum Assisted Wound Therapy in the Outpatient Setting.
Orthoses, Cranial Remodeling
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Orthoses, Cranial Remodeling (May 1, 2013) For cranial remodeling orthoses, see CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics).
Orthoses, Spinal March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Orthoses, Spinal May 1, 2013) NOTE: For self-operated spinal unloading devices, see DME.00025 Self-Operated Spinal
Unloading Devices.
Orthoses, Spinal - Senior
May 13, 2013 AGP MOC review: Added Organizational Policy: Organizational Policy (Orthoses, Spinal - Senior May 13, 2013) NOTE: For self-operated spinal unloading devices, see DME.00025 Self-Operated Spinal
Unloading Devices.
Prosthetics, Above Knee and Below Knee
December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity.
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Above Knee and Below Knee May 1, 2013)
NOTE: For microprocessor controlled lower limb prosthesis, see OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis.
Prosthetics, Above Knee and Below Knee - Senior
December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity -
Senior.
Subject: Customizations to McKesson InterQual® Criteria
Date of Amerigroup Medical Operations Committee ( AGP MOC)
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Customizations
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Above Knee and Below Knee - Senior May 1, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR.00003
Microprocessor Controlled Lower Limb Prosthesis.
Prosthetics, Lower Extremity
December 12, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Lower Extremity December 19, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR.00003
Microprocessor Controlled Lower Limb Prosthesis.
Prosthetics, Lower Extremity - Senior
December 12, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Prosthetics, Lower Extremity - Senior December 19, 2013) NOTE: For microprocessor-controlled lower limb prosthesis, see OR-PR.00003
Microprocessor Controlled Lower Limb Prosthesis.
Prosthetics, Microprocessor-controlled, Knee
December 12, 2013 AGP MPC review: Guideline retired. McKesson replaced guideline with Prosthetics, Lower Extremity. March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Prosthetics, Microprocessor-controlled, Knee (May 1, 2013) For microprocessor-controlled lower limb prosthesis, see OR-PR.00003 Microprocessor Controlled Lower Limb Prosthesis.
Secretion Clearance Devices
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Secretion Clearance Devices (May 1, 2013) For secretion clearance devices, see DME.00012 Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV).
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
Customizations
Secretion Clearance Devices - Senior
March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Secretion Clearance Devices - Senior (May 1, 2013) For secretion clearance devices, see DME.00012 Oscillatory Devices for Airway Clearance, including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV).
Standing Frames March 21, 2013 AGP MPC review: Removed criteria and replaced with the following: Standing Frames (May 1, 2013) For standing frames, see DME.00034 Standing Frames.
Return to Index
CUSTOMIZATIONS LEVEL OF CARE (LOC): OUTPATIENT REHABILITATION & CHIROPRACTIC
Subset Title
Date of Amerigroup Medical Operations Committee ( AGP MOC)
March 21, 2013 AGP MPC review: Added Organizational Policy: Organizational Policy (Traumatic Brain Injury (TBI): Rehabilitation [Adult] May 1, 2013) NOTE: For cognitive rehabilitation, see MED.00081 Cognitive Rehabilitation.
Return to Index
CUSTOMIZATION HISTORY
Date Action Reason
12/19/2013 Release updated document for Customizations to McKesson InterQual® Criteria 2013.
Updated document for Customizations to McKesson InterQual® Criteria 2013. The December 12, 2013 Amerigroup Medical Operations Committee reviewed and approved the following
Subject: Customizations to McKesson InterQual® Criteria
related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.
updates to the 2013.3 Edition: o Removed Customization Care Planning (CP)
Procedures
Ptosis Repair o New Customizations Care Planning (CP) Durable
Medical Equipment
Prosthetics, Lower Extremity
Prosthetics, Lower Extremity – Senior o Retired Customizations Care Planning (CP) Durable
Medical Equipment
Prosthetics, Above Knee and Below Knee
Prosthetics, Above Knee and Below Knee - Senior
Prosthetics, Microprocessor-controlled, Knee
09/27/2013 Release updated document for Customizations to McKesson InterQual® Criteria 2013.
Updated document for Customizations to McKesson InterQual® Criteria 2013. The September 4, 2013 Amerigroup Medical Operations Committee reviewed and approved the following revised customizations to the 2013.2 Edition: o Customizations Care Planning (CP) Procedures
Video Electroencephalographic (EEG) Monitoring
Video Electroencephalographic (EEG) Monitoring (Pediatric)
6/28/2013 Release updated document for Customizations to McKesson InterQual® Criteria 2013.
Updated document for Customizations to McKesson InterQual® Criteria 2013. The May 13, 2013 Amerigroup Medical Operations Committee (formerly Medical Policy Committee) reviewed and approved additional customizations to the 2013 Edition of the InterQual® Criteria.
5/01/2013 Release document for Customizations to McKesson InterQual® Criteria 2013.
New document for Customizations to McKesson InterQual® Criteria 2013. The 2013 Edition of the InterQual® Criteria and corresponding Customized Criteria will take effect May 1, 2013.
